B E H A V I O R A L S C I E N C E S P E C I A L I S T S, L L C 100 WEST THIRD AVENUE, SUITE 200, COLUMBUS, OH 43201-3256 VOICE (614) 291-7600 ● FAX (614) 291-3800 [email protected]

FRANKLIN COUNTY DEPARTMENT OF JOB & FAMILY SERVICES FAX or ELECTRONIC MAIL REFERRAL FORM

This form may be used to refer a patient/consumer to Behavioral Science Specialists, LLC for a basic medical examination or a psychological evaluation. Please fax the completed form to: (614) 291-3800. Alternately, you may complete the form, save it as an MSWord file, and attach it to a secure socket, encrypted electronic mail message addressed to: [email protected].

You will receive an electronic mail message confirming the receipt of your referral and conveying the date and time of the appointment. Likewise, a letter will be mailed to the patient/consumer notifying them of their appointment. Be sure to mail or fax the patient/consumer’s medical or psychological records to the address above.

Please make sure all fields are filled out before submitting.

Patient/Consumer Referral Information (Please Print) Caseworker’s First Name: Caseworker’s Last Name: Caseworker’s Telephone:

Caseworker’s Mailing Address: Caseworker’s Email Address:

Recipient Number (12 digits) Application Date Additional Information:*

Patient/Consumer’s First Name: Patient/Consumer’s Last Name: Patient/Consumer’s Telephone:

Patient/Consumer’s Mailing Address (including City, State, Zip):

Patient/Consumer’s Date of Birth: Patient/Consumer’s Soc. Sec. No.: Is this a New referral, Re-referral or Deferral?

Indicate the services requested:

Yes No Basic Medical Examination and Behavioral Health Screen Yes No Basic Medical Examination Only Yes No Psychological Evaluation Only *FCDJFS is responsible for providing all translation and transportation services for clients.

Confidentiality Notice: This communication is for the sole use of the intended recipient and may contain confidential and privileged information. Any unauthorized review, use, disclosure, or distribution is prohibited. If you are not the intended recipient, please contact the sender, and destroy all copies of the communication.